ENROLLMENT HISTORY - School District of Philadelphia
SCHOOL DISTRICT OF PHILADELPHIA
STUDENT REGISTRATION FORM (EH-40) PARENT / GUARDIAN MUST COMPLETE THIS FORM AND PROVIDE ALL NECESSARY DOCUMENTS
Please Print All
STUDENT INFORMATION - SECTION 1
Last Name
First Name
M.I.
MONTH
Date of Birth
DAY
YEAR
STUDENT ID NUMBER
House No.
Dir
Street Name
St., Ave., Etc.
Apt# Zip Code Phone Number
Race Designation: Is this student Hispanic Yes or No Gender: Male / Female
Check all races that apply: InWfohrimteatioBnlack / African American
Native Hawaiian / Other Pacific Islander
Country of Birth: Home Primary Language Date child first enrolled into a U.S. School
Asian American Indian / Alaska Native
STUDENT ENROLLMENT HISTORY - SECTION 2
Indicate city and type of school child last attended
Philadelphia
Other City:
Public School Non Public School
Date Last Attended Grade Last Attended Name of School Address
City
State
If the student attended school outside of the United States, do you have his/her school records?
Yes:
If yes, please provide a copy for the school __________________________________________________________
No:
If no, please contact the school to obtain the records __________________________________________________
Did the child ever attend: Pre-Kindergarten and/or Kindergarten
1) Has the child ever received Special Education Services in PA or another state? Yes No
2) Does your child have a current IEP?
Yes No
3) Does your child have a current evaluation report?
Yes No
4) Was the child ever enrolled in an Early Intervention Program?
Yes No
5) Has the child ever received ESOL/Bilingual services?
Yes No
6) Does your child have a 504
Yes No
7) Does your child have a Gifted IEP?
Yes No
LANGUAGE SURVEY - SECTION 3
English
1) What language does the family speak at home most of the time?
2) What language does the parent(s) speak to her/his child most of the time?
3) What language does the child speak to her / his parent(s) most of the time?*
4) What language does the child speak to her/his brothers/sisters most of the time?*
5)) What language does the child speak to her/his friends most of the time?*
6) What language does the child speak most frequently?*
If yes, which state: If yes, what If yes, which state:
Other
Language
7) What other languages does the child speak? 1) _____________________ 2) ____________________ 3) ____________________
* If the answer to these questions is other than English, the student must be given the English placement test (W-APT) by a certified administrator.
SCHOOL DISTRICT OF PHILADELPHIA
STUDENT REGISTRATION FORM (EH-40) PARENT / GUARDIAN MUST COMPLETE THIS FORM AND PROVIDE ALL NECESSARY DOCUMENTS
HOUSEHOLD INFORMATION - SECTION 4
Student Resides With:
Both Parents (same address )
Mother
Parent / Guardian Name:
Father
Stepparent
Parent / Guardian Name:
Guardian / Other
(Circle) Mother / Father / Stepparent / Guardian / Other
(Circle) Male / Female
[Active Military] Yes / No
Address:
(Circle) Mother / Father / Stepparent / Guardian / Other
(Circle) Male / Female
[Active Military] Yes / No
e
Address:
Phone: (Home)
(Cell)
(Work)
Phone: (Home)
(Cell) (Work)
Email:
Email:
date:
Preferred Language for School Related Communications:
Preferred Language for School Related Communications:
MCKINNEY-VENTO ELIGIBILITY - SECTION 4 (continued) (THIS INFORMATION WILL BE KEPT CONFIDENTIAL)
Please indicate your current housing status: Rent Lease Own
In a motel/hotel due to loss of housing, economic hardship or similar reason Are you currently living with a family member due to loss of housing, economic hardship or similar reason Did you experience a man-made disaster/fire Did you experience an eviction If the family is eligible for the Homeless Assistance Act of 1987 (known as McKinney?Vento) please contact your school counselor once registration is completed.
SIBLING INFORMATION - SECTION 5
Please list all school aged children (ages 5 and above)
Name
D.O.B.
Current School
Grade Student ID# if available
EMERGENCY CONTACT INFORMATION - SECTION 6 * Please list two LOCAL emergency contacts and their relationship to the child in the event a parent or guardian cannot be reached: Primary
1)
Name
Relationship
Gender: Male / Female
Phone (1)
Secondary 2)
Name
Phone (2) Relationship
Gender: Male / Female
Phone (1)
Phone (2)
By signing below, I am allowing the School District of Philadelphia to register my child as a student. I also certify the information provided on this
application to be true and accurate and providing false or incomplete information that is required for registration may delay enrollment.
Parent / Guardian Signature
Date
Parent / Guardian Signature
Date
................
................
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